A Intermediate Evaluation and Management 1 Focused history and physical check range of motion of the elbow document neurovascular status concomitant and associated orthopaedic injuries 2 Knowledge of imaging studies/lab studies radiographs of the elbow AP lateral oblique 3 Makes informed decision to proceed with operative treatment describes accepted indications and contraindications for surgical intervention 4 Provides postoperative management and rehabilitation postop: 2-3 week postoperative visit wound check check radiograph postop: 4-6 week postoperative visit check radiograph postop: 1 year postoperative visit 5 Diagnose and early management of complications recognize infection B Advanced Evaluation and Management 1 Order appropriate imaging studies radiographs CT scan/3D reconstruction 2 Provides post-op management and rehabilitation increase ROM as healing progresses adequate/proper postop xrays C Preoperative H & P 1 Obtain history and basic physical age gender mechanism of injury skin integrity open/closed injury check neurovascular status need to assess for associated injuries such as radial head and capitellum fractures 2 Splint fracture appropriately place in posterior splint 3 Order basic imaging studies order biplanar radiographs and/or CT scan of the elbow 4 Perform operative consent describe complications of surgery including stiffness wound breakdown heterotopic ossification
E Preoperative Plan 1 Template fracture identify fracture pattern, displacement, comminution, and presence of dislocation 2 Execute surgical walkthrough describe key steps of the operation verbally to attending prior to beginning of case. description of potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation hinged external fixation system 2 Room setup and equipment c-arm perpendicular to OR table 3 Patient positioning supine position arm should be in 90 degrees of flexion place bump under ipsilateral scapula G Construct Assembly 1 Identify the rotational axis locate the rotational axis of the elbow for proper rotation of the external fixator 2 Construct the hinge block assembly it is important in the preoperative preparation that the hinge block assembly for the humeral portion is set up so that the large block is on the medial aspect 3 Adjust the block height accommodate the valgus of the distal humerus by adjusting the block height the upper ring should be perpendicular to the distal humerus and the axis of rotation should still be aligned the average valgus will be approximately 7 degrees H Medial Pin Placement 1 Make the skin incision the most proximal portion of the incision should allow visualization of the upper humerus for placement of the medial pin 2 Identify and mobilize the ulnar nerve 3 Expose the joint of the elbow expose the anterior and posterior elbow joint 4 Excise the intermuscular septum this will expose the anterior distal humerus and capsule 5 Perform a capsular release 6 Excise any heterotopic ossification 7 Lengthen the muscle as needed and reduce the elbow joint 8 Create a fascial sling before closure of the wound, transpose the ulnar nerve and hold it in position with a fascial sling construct the fascial sling in a manner where it does not constrict the nerve during flexion or extension of he elbow 9 Determine the level of pin placement place the compass hinge over the elbow to determine the level of the pin placement place an appropriately sized Steinmann pin up to 3.1 mm across the axis of rotation of the elbow place the compass hinge over the pin 10 Place the medial pin under direct vision, place the medial pin into the humerus posterior to the anteriorly transposed nerve make sure that the pin does not impinge on the vascular structures or the ulnar nerve perfect placement of this pin is essential for alignment of the compass hinge at the elbow 11 Verify placement take AP and lateral radiographic views to ensure the placement is correct judge the superior ring and the relative distance from the medial to the lateral aspect of the elbow it is better to have the arm closer to the medial side of the wheel in comparison to the lateral side of the wheel this allows more adduction of the arm at the side of the patient once the hinge is placed I Half Pin Placement 1 Determine the position of the half pin use the cube assembly for pin placement attach the cube directly to a ring or a construct hinge by attaching a cube to a hinge or a post with a bolt pass the drill guide through the large hole until it touches the skin 2 Appropriately place the incision make an incision at this spot 3 Expose the bone separate the soft tissues and the periosteum 4 Insert the drill guide until it rests on the bone lock the drill guide in place with a set screw or bolt 5 Drill through the bone use a drill bit of the appropriate size and drill though both cortices 6 Determine thickness of the bone determine the bone thickness by reading the number in millimeters indicated on the drill shank on the top of the guide or by hooking the tip of the depth gauge onto the outside of the far cortex and reading the number of millimeters on the top guide choose the appropriate length thread that is designated by the measurement of the cortical width and place the pin through the guide by use of the driver extractor 7 Place self tapping screws 8 Manual placement is recommended for self tapping screws confirm that the pin is seated firmly in both cortices clinically and with image intensification 9 Remove the drill guide 10 Place the centering sleeve slide a centering sleeve of the appropriate size over the pin and align the bold line on the head to point to the threaded hole that will be used to lock the pin this allows the bolt or set screw to impinge on the pin directly this ensures a more secure lock J Humeral Pin Placement 1 Place the superolateral pin place the superolateral pin into the humerus just distal to the deltoid insertion and direct it medially the radial nerve will be posterior to the pin at this level 2 Place the posterolateral pin place the posterolateral humeral pin just anterior to the triceps pin direct this pin from posterolateral to anteromedial the radial nerve will be anterior to this pin 3 Check the alignment of the pins once the pins are attached to the external fixator check that the alignment of the axis is appropriate use the sliding 5/8 inch ring attachment assembly to modify any position from anterior to posterior if needed K Ulna Pin Placement 1 Position the elbow place the elbow in 90 degrees of flexion when placing ulnar fixation if the elbow is grossly unstable, reduce the elbow joint before placing the ulnar pins 2 Place the proximal ulnar pin tighten the pin into place on the ring perpendicular to the ulna place a second pin it is advised to predrill the holes in the ulna due to the size and shape of the ulna 3 If reduction of the joint was performed, check the reduction flex and extend the elbow to ensure there is adequate reduction of the joint 4 Apply distraction after all of the pins are placed, apply distraction to the system by the distraction mechanism loosen the three washer headed screws and apply distraction by adjusting the set screws on either wheel the total distraction permitted is 6 mm 5 Once the humeral fixation is achieved, remove the axis pin at this point evaluate elbow range of motion apply a light dressing around the wounds with sponges over the pins and leave a hemovac drain in place L Elbow Stability Testing 1 Check elbow flexion and extension 2 Check stability in various rotations of the elbow pronation supination neutral N Wound Closure 1 Irrigation and hemostasis irrigate wounds thoroughly deflate tourniquet (if elevated) coagulate any bleeders carefully 2 Dressings apply a light dressing around the wounds with sponges over the pins and leave a hemovac drain in place
O Perioperative Inpatient Management 1 Write comprehensive admission orders IV fluids pain control antibiotics continue antibiotics for 24 hours postoperatively advance diet as tolerated inpatient pt spend the first few days gradually increasing the patients flexion controlled passive stretch of the elbow to gradually improve and overcome the tightness of the triceps muscle once the swelling and immediate postoperative edema has resolved start cycling the elbow from flexion to extension during a 6 to 8 hour period work on achieving greater and greater flexion and extension engage the clutch gradually increase flexion initiate indomethacin therapy to reduce the incidence of heterotopic ossification postoperative radiographs order biplanar radiographs of the elbow wound management 2 Discharges patient appropriately pain meds wound care schedule follow up in 2 weeks outpatient physical therapy R Complex Patient Care 1 Comprehensive pre-op planning/alternatives use of external fixation 2 Modify and adjust post-op plan as needed 3 Understands how to avoid/prevent potential complications 4 Treat simple complications both intraoperatively and postoperatively. revise hardware placement recognize improper hardware position